Healthcare Updates
Objec1ves: Par1cipants will: 1. Describe new medica1ons available for latent and
drug-‐resistant Tuberculosis. 2. List 2 op1ons for a successful colonoscopy prep. 3. List the differences between commonly used blood
thinners. 4. List 2 resources for healthcare updates.
Tuberculosis is either:
Active TB or
Latent TB
Ac#ve TB
New drug just released: Sirturo
Sirturo (bedaquiline) has been approved by the FDA for adults with multi-drug resistant TB. -the first TB medication to be approved in 4 decades. -for active TB that does not respond to treatment with isonazid and rifampin. -adverse effects possible in liver and heart
January 2013:
Latent TB posi1ve reactor, but no ac1ve disease
-‐cannot spread TB to others
5-‐10% will get ac1ve TB at some 1me in their life
at risk: diabe1cs and AIDS, immune system weakened with illness
New 12 Weekly Dose Regimen recommended for:
-‐recent exposure to a person with infec1ous TB disease -‐persons who have a posi1ve tuberculin skin test or a posi1ve blood test for TB (but not ac1ve tb) -‐HIV-‐infected persons who are otherwise healthy and not taking an1retroviral medicines.
Latent TB treatment
now:
Drugs Duration Interval Minimum doses
Isoniazid 9 months Daily 270
Twice weekly* 76
Isoniazid 6 months Daily 180
Twice weekly* 52
Rifampin 4 months Daily 120
Isoniazid and Rifapentine
3 months Once weekly* 12
CDC GUIDELINES: highest risk 1. Foreign-‐born persons who move from countries with a high incidence of TB
CDC GUIDELINES cont.
2. Persons who were homeless, in prison, or from certain nursing home facilities 3. Healthcare workers who may have worked with a TB patient 4. HIV positive persons
Popula1on of Ohio:
11.5 million people
Discussion:
TB Policies for:
ICF: TB control according to American College of Pulmonary Physicians and American Pediatric
Waiver: no regs
Day Programs: infec1on control program
MOST IMPORTANT: EMPLOYEES
Why a 2 step skin test? • in some persons who are infected with tuberculosis, the ability to react to tuberculin may decrease over 1me and they may have a false-‐nega1ve reac1on. The first test may s#mulate the immune system, causing a posi1ve, or boosted reac1on to the second test.
Handy millimeter reference:
Quan# FERON-‐TB Gold: TB blood test (2005)
-‐no need for skin test, more reliable
-‐if posi#ve, s#ll need to dis#nguish if ac#ve or latent, just like TB skin test
Colonoscopy
Cancer Distribu1on
Signs of colon cancer: worsening cons1pa1on, blood in the stool, anemia,
weight loss, fever, loss of appe1te
Higher risk: -‐9 of 10 are people over 50 yrs old
-‐First-‐degree rela1ves (parents, siblings, or children) -‐Exis1ng condi1ons: inflammatory bowel disease
(IBD), ulcera:ve coli:s, Crohn's disease
Screening for people with DD aWer age 50 : colonoscopy every 10 years?
sigmoidoscopy?
annual fecal occult stool? annual CBC?
Colonoscopy preps
Standard preps:
Ideas for people with DD:
1. Clear liquid diet for 2 days, at least 1000 calories: popsicles, jello jigglers, flavored tonic water, sodas,
boullion, sweet tea
2. Mag Citrate/ Mag Citrate/ 4 Dulcolax tabs
3. 4 Dulcolax tabs /Mirilax 238gm / 64 oz. Gatorade
WHY blood thinners are prescribed:
TO Treat & Prevent BLOOD CLOTS
• Blood clot in a vein (DVT: deep vein thrombosis) • Blood clot in the lung (PE: pulmonary embolism)
• To prevent stroke with Atrial Fibrillation: irregular heartbeat
• To prevent heart attack or stroke (if at risk for heart attack, diabetes, TIAs, angina) • Previous heart attack or stroke (prevent another)
• Orthopedic surgeries such as knee or hip replacement
Blood Clot in the Leg
varicose veins vs. blood clot
Risk Factors for DVT:
• Previous clots • Severe infection • Heart failure • Oral contraceptives • Estrogen therapy or pregnancy • Immobility (bed rest, hospitalized, fractures) • Surgery • Cancer How many people in your care are at risk?
Possible signs of DVT: Score
Ac1ve cancer (treatment ongoing, within 6 months or pallia1ve) 1
Paralysis, paresis or recent plaster immobiliza1on of a lower limb 1
Recently bedridden for longer than 3 days or major surgery within 4 weeks 1
Localized tenderness along the distribu1on of the deep venous system 1
En1re leg swollen 1
Calf swelling >3 cm compared with the asymptoma1c leg (measured 10 cm below the 1bial tuberosity)
1
Pidng edema (greater in the symptoma1c leg) 1
Collateral superficial veins (non-‐varicose) 1
Alterna1ve diagnosis as likely or greater than that of DVT (trauma, Baker’s cyst) -‐2
• 3 points or more = high probability, about 75% risk of DVT • 1–2 points = moderate probability, about 17% risk of DVT • 0 points = low probability, about 3% risk of DVT
ATRIAL FIBRILLATION (A fib)
Rapid and disorganized heartbeat. The rate of impulses through the atria can range from 300 to 600 bpm, with an
irregular heartbeat 50-‐150. Blood clots may form when the heart will beat too fast or out of rhythm, and can travel to the
brain (STROKE).
Most common causes • Hypertension (high blood pressure)
• Coronary artery disease • Heart valve disease
• Heart surgery • Chronic lung disease
• Heart failure • Cardiomyopathy
• Congenital heart disease • Pulmonary embolism
• Less common causes • Hyperthyroidism
• Pericardi1s • Viral infec1on
How many people in your care are at risk?
• Rapid and irregular heartbeat • Fluttering or “thumping” in the chest • Dizziness • Shortness of breath and anxiety • Weakness • Faintness or confusion • Fatigue when exercising • Sweating • Chest pain or pressure
Symptoms of A fib:
Types of Blood Thinners
1. Anticoagulants, such as Warfarin (Coumadin), lengthen the time it takes to form a blood clot. New: Xarelto, Eliquis, Pradaxa - the standard treatment for DVT and Atrial Fib
1. Antiplatelet drugs, such as Aspirin and Plavix, prevent blood cells called platelets from clumping together to form a clot.
- the standard treatment for heart attack and stroke prevention
Coumadin (Warfarin)
New an1coagulants like Pradaxa
All new agents compared with warfarin
Advantages: • No monitoring required
• No variability • Fast onset of ac1on • Fast offset • Lower IC hemorrhage rates (about 50% lower for all)
Disadvantages: • No reversibility • No monitoring • Expensive (higher 1er by PBM)
• Not once-‐daily in AM • Less clinical experience
• No data for cardiac issues other than NVAF
Plavix:
for people who have suffered from a recent heart ahack or stroke, or who have peripheral arterial
disease
IVC filters (Intra Vena Cava filters) might be considered when anticoagulation is contraindicated. How they work: trap the blood clots from the legs to prevent traveling to lungs (pulmonary embolus) or brain (stroke). Types:
Discussion: implica1ons for our individuals head injuries
(falls, seizures, SIB)
What are your guidelines when on a blood thinner?
Hypoglycemia: a MIS-‐MATCH
of FOOD, ACTIVITY, AND MEDS
Hypoglycemia: can cause abnormal heart rhythms
and sudden cardiac death
blood sugar less than 70 Hormones released: adrenalin, cor1sol, glucagon, growth
swea1ng, tremor, ↑ pulse, nervous, hunger
blood sugar less than 50 brain not func1oning well:
confusion, ↓decision-‐making skills ↓ reflexes
blood sugar less than 30 coma, death
Cryer PE, Davis SN (2012): Harrison's Principles of Internal Medicine; Holt RIG, Hanley NA (2007): Essen1al Endocrinology and Diabetes.
Hypoglycemia unaware:
-‐on Beta Blocker (atenolol, metaprolol, coreg, inderal, etc.)
-‐older people
-‐have diabe1c neuropathy
-‐have frequent bouts of low blood sugar
Other new info
NEW procedure for severe asthma:
Bronchial thermoplasty is a non-‐drug procedure for severe persistent asthma in pa1ents 18 years and older whose asthma is not well
controlled with inhaled cor1costeroids and long-‐ac1ng beta-‐agonists.
Thermal energy is applied to the airway wall to reduce excessive airway smooth muscle. This decreases the ability of the airways to constrict.
Bronchial thermoplasty
Superbugs: acquired during hospitaliza1on can enter a pa#ent through surgical wounds, catheters, and IVs. Uncontrolled, they con1nue to move throughout the body,
ahacking a person's organs. Includes: enterococci, staphylococci, klebsiella, acinetobacter,
pseudomonas, and enterobacter, which have developed mul#ple resistance
Men taking calcium supplements: 20 % HIGHER RISK OF HEART ATTACK
Data from the National Institutes of Health-AARP Diet and Health Study, which enrolled almost 600,000 adults ages 50 to 71 in 1995 and 1996. Among the 388,229 participants included in the analysis, 56 percent of women and 23 percent of men reported using calcium supplements, while 58 percent and 56 percent reported taking multivitamins that contained calcium. Compared with men who did not take calcium supplements, those taking more than 1,000 mg per day had a 20 percent higher risk of dying from cardiovascular disease, National Cancer Institute in Bethesda, Md., and reported in JAMA Internal Medicine
Evidenced-‐Based Resources
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